Punctal plugs play an integral role in managing our dry eye patients. They deliver a number of benefits to patients by retaining additional tears on the ocular surface by occluding the lacrimal drainage system. The benefits of punctal occlusion to treat dry eye include symptomatic relief, improved tear film break-up times, improved corneal fluorescein staining, increased lower tear meniscus height, improved visual acuity, increased aqueous tear production, improved conjunctival squamous metaplasia grades and goblet cell density, and reduced dependency on artificial lubricants.1-7

Who is a Candidate?
In healthy individuals, an auto-regulatory response adjusts the basal tear volume produced—tear production decreases in response to punctal plug insertion.2,8 In dry eye patients, the auto-regulatory mechanism appears to be malfunctioning—the lacrimal unit does not produce tears in a conducive manner to support optimal ocular surface function.

It has been well accepted that, for patients with dry eye, the common treatment algorithm involves minimizing much of the inflammation from the ocular surface through the use of artificial tears, nutritional supplementation, immunomodulators and/or steroids and then occluding the punctum in order to have the best chance to retain tears that are healthy and are not oversaturated with inflammatory markers. Research has indicated that patients who had their lower puncta occluded and were using cyclosporine b.i.d. O.U. had significantly greater dry eye improvement compared to using either treatment option alone.9

The Contact Lens Challenge
Contact lenses introduce a unique challenge to the ocular surface; the health of the ocular surface now has to be balanced against the introduction of the contact lens to the eye. As such, contact lens wear can illicit dry eye symptoms in individuals who might otherwise have virtually no symptoms. In fact, literature states that over 50% of patients who wear contact lenses complain of discomfort.10,11

We have a number of strategies to increase contact lens comfort including treating underlying ocular surface disease, supplementing lens wear with contact lens rewetting drops, optimizing the contact lens solution and optimizing the contact lens material and design.

Determining The Next Step
For contact lens wearers, the goal is to maximize comfort. Practitioners must sort through a range of options to determine the optimal treatment protocol that will improve their patient’s comfort level. As practitioners, we must understand that comfort is a remarkably subjective term that needs to be viewed as a continuum of a scale of comfort as opposed to an absolute. A person is not necessarily just “comfortable” or “uncomfortable” but rather located at different points on a comfort continuim.

One of our goals with contact lens patients is to continuously improve their wearing experience through increased lens comfort. With every patient who does not complain about uncomfortable lenses at their visit, we try to find a different aspect of their regimen to improve—to further increase their comfort. For patients with comfort complaints, we have created a very strategic approach to better achieve comfort.

• First, we optimize the ocular surface and mitigate any effects that suboptimal health would have on contact lens comfort (to be discussed at length in a future column).

• Next, assuming that the patient has a healthy ocular surface, we focus on contact lens care and look for ways to modify the regimen to optimize comfort. This entails getting a true account of the patient’s care routine and making sure that he or she is using the solutions that will most likely improve the wearing experience. If your patient has strayed from prescribed wear and care patterns, take the time to go over proper care techniques.

• Review the patient’s contact lens prescription. Remember that we, as practitioners, have a number of contact lens materials and designs that can improve the comfort level that a patient is experiencing. Silicone hydrogel lenses, in particular, have been designed to maximize oxygen permeability while maximizing comfort through significant technological advances in surface chemistry.

• Finally, if the above steps have been taken and the patient still complains of lack of comfort, the next logical step is to promote additional moisture to the ocular surface. This can be done by introducing rewetting drops, punctal occlusion or a combination of the two. If patients are using rewetting drops three times or more each day, we tend to proceed with occlusion of both lower puncta.

The Role of Punctal Occlusion
There have been a few studies on punctal occlusion and their effect on contact lens comfort. Daniel Giovagnoli, O.D., and colleagues studied contact lens wearers who complained of decreased comfort. Participants had a punctal plug inserted in the lower punctum of one eye and a sham procedure on the other eye; the patients were unaware that a plug was not placed in the other punctum. Three weeks following the plug placement, there was a significant increase in comfortable contact lens wearing time in the eye that had the punctal plug.12

Julia Geldis, O.D., M.S., and Jason Nichols, O.D., M.P.H, Ph.D, randomized patients complaining of dry contact lenses to both lower puncta being occluded or no punctal occlusion, but the patient went through a sham procedure where the lower puncta were manipulated as if being occluded. Six weeks later, no significant difference existed between the two groups.13

Although there are mixed results in the literature regarding the use of punctal occlusion with contact lens wearers, our personal experience is that when we follow the steps outlined above, we see a relatively high rate of success with punctal occlusion in contact lens wear (see “Treatment Algorithm to Maximize Contact Lens Comfort”).

A Case Study
A 26-year-old Caucasian female toric contact lens wearer came in for her yearly exam complaining of contact lens discomfort. Her ocular surface and anterior segment examination was unremarkable. The contact lens care system that she was utilizing was the one that was recommended and she reported good compliance with lens replacement and lens care. The contact lens material and design were optimized for the patient. Although she noticed significant improvement in her symptoms, she still felt that her comfort was less than she expected. Both lower puncta were occluded O.U. and she was seen 10 days later. Her symptoms were significantly improved. Six months later, her contact lenses continue to be comfortable.

By identifying patient characteristics in our contact lens wearers that would be ideal for earlier intervention of punctal occlusion, we would be able to target the treatment sooner and thus, maximize comfort for our patients. 

1. Chen F, Wang J, Chen W, et al. Upper punctal occlusion versus lower punctal occlusion in dry eye. Invest Ophthalmol Vis Sci. 2010 Nov;51(11):5571-7.
2. Chen F, Shen M, Chen W, et al. Tear meniscus volume in dry eye after punctal occlusion. Invest Ophthalmol Vis Sci. 2010 Apr;51(4):1965-9.
3. Baxter SA, Laibson PR. Punctal plugs in the management of dry eyes. Ocul Surf. 2004 Oct;2(4):255-65.
4. Altan-Yaycioglu R, Gencoglu EA, Akova YA, et al. Silicone versus collagen plugs for treating dry eye: results of a prospective randomized trial including lacrimal scintigraphy. Am J Ophthalmol. 2005 Jul;140(1):88-93.
5. Dursun D, Ertan A, Bilezikçi B, et al. Ocular surface changes in keratoconjunctivitis sicca with silicone punctum plug occlusion. Curr Eye Res. 2003 May;26(5):263-9.
6. Balaram M, Schaumberg DA, Dana MR. Efficacy and tolerability outcomes after punctal occlusion with silicone plugs in dry eye syndrome. Am J Ophthalmol. 2001 Jan;131(1):30-6.
7. Willis RM, Folberg R, Krachmer JH, Holland EJ. The treatment of aqueous-deficient dry eye with removable punctal plugs. A clinical and impression-cytologic study. Ophthalmology. 1987 May;94(5):514-8.
8. Yen MT, Pflugfelder SC, Feuer WJ. The effect of punctal occlusion on tear production, tear clearance, and ocular surface sensation in normal subjects. Am J Ophthalmol. 2001 Mar;131(3):314-23.
9. Roberts CW, Carniglia PE, Brazzo BG. Comparison of topical cyclosporine, punctal occlusion, and a combination for the treatment of dry eye. Cornea. 2007 Aug;26(7):805-9.
10. Nichols JJ, Ziegler C, Nichols KK. Self-reported dry eye disease across refractive modalities.  Invest Ophthalmol Vis Sci. 2005 Jun;46(6):1911-4.
11. Guillon M, Maissa, C. Dry eye symptomatology of soft contact lens wearers and nonwearers.  Optometry Vis Sci. 2005 Sep;82(9):829-34.
12. Giovagnoli D, Graham SJ. Inferior punctal occlusion with removable silicone punctal plugs in the treatment of dry-eye related contact lens discomfort. J Am Optom Assoc. 1992 Jul;63(7):481-5.
13. Geldis JR, Nichols JJ. The impact of punctal occlusion on soft contact lens wearing comfort and the tear film. Eye Contact Lens. 2008 Sep;34(5):261-5.